2019 Health Plus Plan - Small Employer - HorizonBlue.com - Horizon Blue Cross Blue Shield
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2019 Health Plus Plan Small Employer HorizonBlue.com
Health Plus Plan Now you can save on Dental, Vision and Life Insurance with Horizon Blue Cross Blue Shield of New Jersey's Health Plus Plan, a comprehensive, high-quality package all for one competitive rate.
Health Plus Plan Benefits In addition to health benefits, dental, vision and life coverage can help attract, protect and retain valued employees. Horizon Dental Proper dental care can help with more than clean teeth. It can also help detect serious health risks, like diabetes, heart disease and some cancers. Horizon Dental offers affordable plans to meet your employees' needs and includes: ►► One of the largest dental networks in New Jersey, with more than 6,500 offices to access care ►► Access to some of the deepest discounts in the state, which extend beyond plan maximums ►► Little-to-no out-of-pocket expenses for preventive services Horizon Vision Protect your health and dollars with regular eye exams that can detect potential health issues, such as hypertension and diabetes. We can help your employees save on vision exams, eyeglasses and more. Horizon Vision plans offer: ►► Low-cost annual eye exam, including dilation ►► Coverage for eyeglasses and contact lenses ►► Access to a nationwide network through the Horizon/Davis Vision View Network with over 70,000 independent providers and retailers Life and Accidental Death & Dismemberment USAble Life’s Small Group Plans for Life and Accidental Death & Dismemberment offer employers with two to 50 employees the ability to provide your employees a quality benefits package and maintain your bottom line.
Plan Benefits - Low Option
Horizon Dental Benefits
Benefit Low Option
Under 19 Age 19 & Over
Plan Horizon Family Grins
Coinsurance 100/80/50% 100%/Discount/Discount
Annual Maximum None None
MOOP $350/$700 None
Deductible
Single $25 Preventive None
Family $100/$200 Class II & III None
Preventive & Diagnostic 100% 100%
Minor Restorative 80% 100%
Endodontics/Periodontics/Oral Surgery 80% Discount
Major Care 50% Discount
Orthodontia (Medically Necessary) 50% MOOP Applies N/A
Orthodontia (Cosmetic) 50% 25% Discount
Lifetime Maximum $1,000 N/A
Waiting Periods None None
If you require coverage outside of New Jersey, you must select the High Option.
Horizon Vision Benefits
Benefit Low Option
Plan Vista II
Eye Exam (Every Year) $10 Copay
Spectacle Lens (Every Year) $25 Copay
Eyeglass Frame (Every Other Year) $100 Allowance or $150 at Visionworks
Contact Lens in Lieu of Eyeglasses (Every Year) $100 Allowance
USAble Life Insurance
Benefit Small Group Plan
Work Requirement Active full-time employees working 25 hours or more per week
Employee Life and AD&D Benefit $25,000
Dependent Life Benefits
Eligible Spouse $5,000*
Eligible Child(ren) to age 26 $2,000*
*$100 from 14 days to 6 months.
Benefits for employees reduce to 65% at age 65 and reduce to 50% of the pre-age 65 amount at age 70. All amounts of coverage are issued on a guaranteed basis.
Plan Rates
Enrolled Group
Plan Single Two Adults Parent & Child Family
Size
2-4 Low Option $26.60 $44.71 $67.81 $94.33
5-9 Low Option $24.20 $37.81 $52.98 $76.20
10-24 Low Option $22.30 $34.34 $47.29 $67.39
25-49 Low Option $20.99 $31.94 $38.38 $53.60
Rates are guaranteed for two years from the initial effective date of the policy.Plan Benefits - High Option
Horizon Dental Benefits
Benefit High Option
Under 19 Age 19 & Over
Plan Horizon Family Grins Plus
Coinsurance 100/80/50% 100/80/50%
Annual Maximum None $1,000
MOOP $350/$700 None
Deductible
Single $25 Preventive $50
Family $100/$200 Class II & III $150
Preventive & Diagnostic 100% 100%
Minor Restorative 80% 80%
Endodontics/Periodontics/Oral Surgery 80% 80%
Major Care 50% 50%
Orthodontia (Medically Necessary) 50% MOOP Applies N/A
Orthodontia (Cosmetic) 50% N/A
Lifetime Maximum $1,000 N/A
Waiting Periods None None
If you require coverage outside of New Jersey, you must select the High Option.
Horizon Vision Benefits
Benefit High Option
Plan Panorama IVB
Eye Exam (Every Year) $10 Copay
Spectacle Lens (Every Year) $25 Copay
Eyeglass Frame (Every Other Year) $130 Allowance or $180 at Visionworks
Contact Lens in Lieu of Eyeglasses (Every Year) $130 Allowance
USAble Life Insurance
Benefit Small Group Plan
Work Requirement Active full-time employees working 25 hours or more per week
Employee Life and AD&D Benefit $25,000
Dependent Life Benefits
Eligible Spouse $5,000*
Eligible Child(ren) to age 26 $2,000*
*$100 from 14 days to 6 months.
Benefits for employees reduce to 65% at age 65 and reduce to 50% of the pre-age 65 amount at age 70. All amounts of coverage are issued on a guaranteed basis.
Plan Rates
Enrolled Group
Plan Single Two Adults Parent & Child Family
Size
2-4 High Option $ 51.36 $ 94.23 $ 100.07 $ 152.24
5-9 High Option $ 46.09 $ 77.91 $ 77.99 $ 124.91
10-24 High Option $ 41.97 $ 70.38 $ 69.49 $ 111.15
25-49 High Option $ 39.36 $ 65.61 $ 57.25 $ 92.46
Rates are guaranteed for two years from the initial effective date of the policy. Please note the initial bill, as well as all future billing and administration for the Life/AD&D portion of this
plan will be administered directly by USAble Life.Our new Horizon Blue app
puts care and support
in your hand.
Downloading is easy and free. And you’ll be
connected 24/7 to all your benefits, access to
care and Horizon BCBSNJ support.
Text GetApp to 422-272 for your free Horizon Blue download.
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*USAble Life is an independent company that operates separately from Horizon BCBSNJ. USAble Life does not sell or service Horizon BCBSNJ products and is solely
responsible for the life, disability and accident products referenced herein.
Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross® and Blue Shield®
names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name and symbols are registered marks of
Horizon Blue Cross Blue Shield of New Jersey.
Apple and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc., registered in the U.S. and other
countries. Google Play and the Google Play logo are trademarks of Google LLC.
*There is no charge to download the Horizon Blue app but rates from your wireless provider may apply.
Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, gender, national origin,
age, disability, pregnancy, gender identity, sex, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Spanish
(Español): Para ayuda en español, llame al 1-866-660-6528. Chinese (中文): 如需中文協助，請致電 1-866-660-6528.
EC001493 (0918)Three Penn Plaza East
Newark, NJ 07105-2200
HorizonBlue.com
Notice of Nondiscrimination
Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws
and does not discriminate against nor does it exclude people or treat them differently on the basis
of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual
orientation or health status in the administration of the plan, including enrollment and benefit
determinations.
Horizon BCBSNJ provides free aids and services to people with disabilities to communicate
effectively with us, such as qualified sign language interpreters and information written in other
languages.
Contacting Member Services
Please call Member Services at 1-800-355-BLUE (2583) (TTY/TDD 711) or the phone
number on the back of your member ID card, if you need the free aids and services noted
above and for all other Member Services issues, including:
• Claim, benefits or enrollment inquiries
• Lost/stolen ID cards
• Address changes
• Any other inquiry related to your benefits or health plan
Filing a Section 1557 Grievance
If you believe that Horizon BCBSNJ has failed to provide the free communication aids and
services or discriminated on the basis of race, color, gender, national origin, age or disability you
can file a discrimination complaint also known as a Section 1557 Grievance. Horizon BCBSNJ’s
Civil Rights Coordinator can be reached by calling the Member Services number on the back of
your member ID card or by writing to the following address:
Horizon BCBSNJ – Civil Rights Coordinator
PO Box 820
Newark, NJ 07101
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Office for Civil Rights Headquarters
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019 or 1-800-537-7697 (TDD)
OCR Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.
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Horizon Blue Cross Blue Shield of New Jersey Arabic
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